RESULTS  OF  BRAIN 

SUROERY  IN  EPILEPSY"  AND  CONOENITAL 
• MENT^'  JDEPi&ST.  ^ ^ " 


WIT^LIAM  F*.  SF»RATLI]S^G,  M.  D. 


UEl?rtINTKr>  KROM 

t*'ROCEEr)lNGS  OIT  AMERICAN  MEOICO-RR YCHOEOGtCAE  AHSOCIATTON* 


WASHINGTON,  I>.  C.,  MAY,  1003. 


' : ’ 1 


■y-'> 


RESULTS  OF  BRAIN  SURGERY  IN  EPILEPSY  AND 
CONGENITAL  MENTAL  DEFECT.* 


By  William  P.  SpraMing^  M.  D., 

Medical  Superintendent  of  the  Craig  Colony  for  Epileptics,  Etc., 
Sonyea,  N.  Y. 

Since  surgical  intervention  is  practised  in  epilepsy  for  the 
possible  relief  of  conditions  of  certain  types,  and  in  idiocy  and 
imbecility  for  the  possible  relief  of  certain  conditions  of  other 
types,  we  can  readily  divide  the  subject  into  two  parts,  taking 
up  epilepsy  first.  The  limit  on  time  requires  that  both  be 
treated  in  a greatly  abridged  form. 

THE  TYPE  OF  EPILEPSY  PROPOSED  FOR  SURGICAL  TREATMENT 
SHOULD  BE  SPECIFIED. 

Used  without  qualification,  the  word  “epilepsy”  carries  little 
meaning  to  the  analytical  student  of  the  disease.  So  varied  is 
its  etiology,  and  so  numerous  are  its  types,  that  the  synthetical 
designation  of  “epilepsy”  only  has  but  little  value. 

In  some  epilepsies  medical  treatment  promises  most;  in  others, 
surgical;  and  it  is  well  to  differentiate  the  cases  of  each  at  the 
outset,  doing  this  broadly,  if  not  specifically,  always  reserving, 
however,  specific  distinctions  before  undertaking  the  surgical 
treatment  of  any  particular  case. 

We  may  first  lay  down  this  general  rule:  The  epilepsies  that 
most  seriously  impair  the  conscious  operations  of  the  mind  are 
less  amenable  to  treatment  by  the  surgeon  than  the  epilepsies 
that  leave  the  mind  most  largely  unaffected. 

There  is  a vast  difference  between  fits  of  different  types  in 
the  degree  in  which  they  affect  the  mind.  Some  blot  it  out  in  a 
flash,  completely  and  instantaneously;  others  blot  it  out  gradu- 
ally; others  impair  it  in  various  degrees  without  effecting  its 

* Read  at  the  Annual  Meeting  of  the  American  Medico-Psychological 
Association,  held  at  Washington,  D.  C.,  May,  1903. 


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BRAIN  SURGERY. 


complete  destruction  at  any  time  during  the  fit;  while  still  others 
do  not  even  disturb  it  in  an  appreciable  degree,  the  latter  being 
the  case  with  the  milder  monospasms,  Jacksonian  in  character. 

This  being  true,  we  first  single  out  the  epilepsies  that  mostly 
affect  the  motor  side  of  the  body  as  promising  most  for  surgical 
treatment,  to  the  exclusion  of  those  that  invade  the  psychic  side 
to  the  greatest  degree. 

We  may  illustrate  this  by  saying  - that  in  grand-mal  convul- 
sions in  which  consciousness  is  destroyed  through  the  intensity 
of  the  “ explosive  discharge  ” or  through  the  sudden  snapping 
of  restraint  ” in  the  motor  zones,  surgical  measures  are  far 
more  rational  than  when  the  attacks,  being  psychic,  are  silent  in 
forrp,  causing  no  commotion  in  the  muscular  system  and  no 
change  in  body  posture. 

Operations  for  the  possible  relief  of  epilepsy  should  be  con- 
fined to  cases  in  which  the  attacks  are  grand-mal  or  Jacksonian, 
and  will  seldom  be  found  of  any  use  in  petit  mal  or  psychic 
types. 

This  takes  no  account  of  partial,  reflex,  or  other  rudimentary 
forms  of  the  disease,  many  of  which  are  well  adapted  to  surg- 
ical treatment,  being  due  as  they  are  to  puch  causes  as  old 
cicatrices,  an  adherent  prepuce,  foreign  growths  in  the  nose^ 
middle-ear  disease,  and  other  peripheral  organic  conditions, 
including  recent  injuries  to  the  brain  in  which  the  early  repair 
of  the  damage  removes  the  cause  of  the  attacks. 

RESULTS  OF  BRAIN  SURGERY  IN  THIRTY- THREE  CASES  OF 
EPILEPSY. 

The  types  of  epilepsy  in  which  surgical  intervention  is  often- 
est  a rational  proceeding  comprise  the  bulk  of  all  the  epilepsies. 
In  1325  cases  that  have  come  under  my  observation  during  the 
past  eight  years,  774  were  grand-mal  and  9 Jacksonian;  together 
a little  over  60  per  cent  of  the  gross  number.  We  do  not  wish 
to  be  understood  as  claiming  that  60  per  cent  or  over  are  sub- 
jects for  surgical  treatment;  we  mean  that  there  are  60  per  cent 
only  in  which  some  cases  will  be  found  that  surgery  may  bene- 
fit. 

Before  operating  in  any  case,  the  patient  should  be  carefully 
watched  so  that  the  exact  order  of  invasion,  the  precise  manner 
in  which  the  fit  begins,  the  manner  in  which  it  extends,  involv- 


REMOTE  STORAGE 


•S  p 


W.  P.  SPRATLING. 


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ing  one  group  of  muscles,  one  part  of  the  body  after  the  other, 
should  be  carefully  observed  on  repeated  occasions,  together 
with  the  nature,  frequency  and  recurrence  of  the  aura;,  for  all 
these  constitute  valuable  signs  that  help  to  guide  us  to  the  cer- 
ebral seat  of  the  disease.  The  study  of  such  symptoms  to  their 
full  advantage  demands  a knowledge  of  cerebral  localization  we 
cannot,  either  as  epileptologists  or  as  surgeons,  fail  to  acquire. 

We  can  form,  in  a measure,  some  idea  of  the  value  of  brain 
surgery  in  epilepsy  by  noting  the  results  in  the  33  cases  pre- 
A sented  at  this  time.  All  of  them  have  been  under  my  daily 
observation  for  periods  varying  from  one  to  eight  years.  Five 
of  these  operations  were  performed  at  the  colony  in  cases  se- 
lected with  great  care.  The  remaining  28  were  operated  on 
■ prior  to  their  admission. 

i£  Case  1. — Male,  aged  29  years.  Family  history  negative.  Epilepsy 
, began  at  17  years.  Supposed  to  be  caused  by  malaria.  Trephined, 

October,  1895,  six  years  after  the  first  seizure. 

Result:  No  improvement. 

Case  2. — Male,  aged  31  years.  Father  tuberculous;  otherwise  family 
history  negative.  Epilepsy  began  at  13  years.  Supposed  to  have  been 
caused  by  trauma  to  bead.  Trephined  in  August,  1894.  Right  motor 
fv/  region.  Operation  11  years  after  the  onset  of  the  epilepsy. 

*'"■  Result:  No  improvement. 

Case  3. — Male,  aged  22  years.  Family  history  negative.  Epilepsy 
began  at  15  years.  No  assigned  cause.  Patient  grew  steadily  worse 
V and  bad  as  many  as  24  attacks  daily.  Trephined  in  October,  1897, 
three  years  after  the  onset  of  the  epilepsy.  Since  the  operation  the 

Vr:attacks  have  been  less  frequent,  but  more  severe.  Trephined  again  at 
the  Craig  Colony  in  April,  1900.  His  attacks  bad  been  growing  steadily 
worse.  A portion  of  thickened  and  adherent  dura  was  removed.  Since 
^ the  last  operation  bis  attacks  have  been  markedly  lessened  in  fre- 
^ quency.  On  large  doses  of  bromides  ever  since  the  operation. 

Result:  Great  decrease  in  frequency  and  severity  of  attacks. 

Case  4. — Male,  aged  31  years.  Mother’s  father  insane  and  syphilitic. 
.Mother’s  sister  committed  suicide.  Brother  and  sister  died  in  convul- 
sions. Paternal  relatives  intemperate.  Epilepsy  began  at  age  of  17 
years.  Supposed  to  be  caused  by  an  injury  to  the  head  when  7 years 
old.  Trephined  during  1895,  eight  years  after  the  onset  of  the  epilepsy. 
^ Result:  No  improvement. 

^ Case  5. — Male,  aged  38  years.  Maternal  grandmother  had  epilepsy. 

Assigned  cause  of  epilepsy,  heredity.  Trephined  over  the  left  motor 
, '^gion  in  1893,  fifteen  years  after  the  onset  of  the  epilepsy. 

^ Result:  Slight  temporary  benefit. 


V 

VI 


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BRAIN  SURGERY. 


Case  6. — Male,  aged  8 years.  Family  history  negative.  Epilepsy 
began  at  5 years.  Supposed  to  have  been  due  to  a fall  on  the  head. 
Two  months  after  the  fall  he  had  the  first  attack.  Attacks  increased 
In  frequency  and  at  the  age  of  5 years  he  was  having  50  attacks  a day. 
Two  years  after  the  injury  he  was  trephined  over  the  right  motor 
region.  Since  the  operation  he  has  had  no  attacks  during  the  daytime. 

Result:  Decrease  in  number  of  attacks. 

Case  7. — Male,  aged  30  years.  Mother  rheumatic.  Father  inebriate 
and  died  of  tuberculosis.  Epilepsy  began  at  21  years.  Assigned  cause, 
injury  to  left  side  of  the  head.  Was  run  over  by  a wagon.  Two  weeks 
later  he  had  the  first  attack.  Attacks  at  first  3 or  4 daily.  One  week 
after  the  first  attack  he  was  trephined.  Since  the  operation  his  attacks 
have  been  about  20  each  month. 

Result:  No  improvement. 

Case  8. — Male,  aged  19  years.  Family  history  negative.  Epilepsy 
began  at  11  years.  Was  struck  on  the  head  with  a bale-stick  and  had 
a severe  convulsion  half  an  hour  later.  Second  attack  occurred  one 
month  later  and  then  they  occurred  with  increasing  frequency.  Tre- 
phined in  1896,  three  years  after  injury.  No  benefit  as  the  result  of  the 
operation.  In  April,  1900,  he  was  trephined  again  at  the  Craig  ‘Colony. 
This  time  the  opening  was  made  over  the  left  parietal  bone,  as  this 
was  the  side  injured.  (The  first  operation  was  performed  on  the  right 
side.)  No  adhesions  nor  gross  pathological  changes  were  exposed. 
He  has  about  4 grand-mal  attacks  each  month  at  present. 

Result:  No  improvement. 

Case  9. — Male,  aged  20  years.  Family  history  negative.  Epilepsy 
began  at  7 years.  Supposed  to  be  due  to  an  injury  to  his  head,  which 
occurred  when  he  was  3 years  old.  Trephined  in  February,  1899,  16 
years  after  the  injury  which  was  the  supposed  cause  of  his  epilepsy. 
Attacks  at  first  were  all  psychic,  but  gradually  have  changed  to  grand- 
mal. 

Result:  No  improvement. 

Case  10. — Male,  aged  20  years.  Mother  died  of  tuberculosis.  Maternal 
grandmother  and  aunt  died  of  tuberculosis.  Epilepsy  began  at  age  of 
12  years.  Assigned  cause,  a penetrating  wound  of  the  skull  caused  by 
a nail  when  8 years  old.  Four  years  after  the  injury  he  had  the  first 
attack.  Trephined  over  the  left  parietal  region  in  1899.  Trephined 
again  at  the  Craig  Colony  in  November,  1900,  over  the  same  area  as  at 
first  operation.  Thickened  dura  removed  and  gold  foil  inserted. 

Result:  No  improvement. 

Case  11. — Male,  aged  36  years.  Father  inebriate.  Maternal  uncle  and 
aunt  insane.  Mother  and  grandmother  had  heart  disease.  Epilepsy 
began  at  34  years.  Supposed  to  be  due  to  trauma  to  head  at  the  age 
of  23  years.  Claims  he  had  a fracture  of  the  skull  at  that  time.  In 
July,  1898,  he  fell  from  a ladder  and  had  a convulsion  12  hours  later. 
Since  then  he  has  had  attacks  every  6 weeks.  In  September,  1899,  he 


W.  P.  SPRATLING. 


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was  trephined  over  the  left  frontal  region  at  the  Presbyterian  Hospital, 
New  York.  Six  weeks  after  the  operation  he  had  another  attack.  In 
March,  1901,  he  was  placed  on  bromide  treatment  and  during  the  six 
months  since  that  time  he  has  had  no  attacks. 

Result:  Temporary  improvement,  probably  not  due  to  operation. 

Case  12. — R.  J.  Me.,  male,  aged  11  years.  Mother  neurotic.  Maternal 
grandmother  had  2 strokes  of  paralysis.  Epilepsy  began  at  8 years. 
In  January,  1898,  he  fell  8 feet  from  a shed  and  struck  the  right  side 
of  his  head.  Had  a convulsion  the  same  day  he  met  with  the  accident. 
In  April,  1900,  over  two  years  after  the  accident,  he  was  trephined 
over  the  right  side  of  the  head  at  the  seat  of  the  injury. 

Result:  No  improvement. 

Case  13.  J.  S.,  male,  aged  31  years.  Nothing  known  of  family  his- 
tory. Epilepsy  began  at  age  of  19  years.  Supposed  to  be  caused  by 
yellow  fever,  contracted  while  in  Brazil  in  1891,  since  shortly  after  this 
he  had  his  first  convulsion.  In  1893  he  was  trephined  over  the  right 
frontal  region,  2 years  after  the  onset  of  the  epilepsy. 

Result:  No  improvement;  attacks  more  frequent  after  operation. 

Case  14. — W.  F.  C.,  male,  aged  20  years.  Family  history  negative. 
Epilepsy  began  at  age  of  15  years.  At  age  of  5 years  he  was  pushed  off 
a wagon  and  injured  his  spine.  Had  first  attack  one  month  after  the 
injury.  In  1897  he  fell  from  an  engine  and  remained  unconscious  for 
some  time.  In  September,  1900,  he  was  trephined,  4 years  after  the 
onset  of  the  disease. 

Result:  No  improvement. 

Case  15. — E.  K.,  male,  aged  15  years.  Family  history  negative.  Epi- 
lepsy began  at  6 years.  Assigned  cause,  trauma.  He  was  hit  on  the 
head  with  a shovel  about  one  month  before  the  first  attack.  Had 
attacks  every  2 or  3 days.  In  January,  1901,  he  was  trephined  over  the 
site  of  the  injury.  Operation  9 years  after  the  injury.  Since  the 
operation  the  attacks  have  been  more  frequent  and  severe. 

Result:  No  improvement;  disease  exaggerated. 

Case  16. — J.  M.  P.,  male,  aged  19  years.  Family  history  negative. 
At  age  of  6 years  he  was  struck  on  the  head  by  a train.  Eight  years 
after  he  had  the  first  convulsion,  and  he  has  had  them  about  every  10 
days  since.  In  January,  1900,  he  was  trephined  over  the  site  of  the 
injury.  Operation  4 years  after  the  onset  of  the  disease.  Attacks  have 
been  worse  since  the  operation. 

Result:  No  improvement;  disease  exaggerated. 

Case  17. — Male,  aged  29.  Family  history  negative.  Epilepsy  began 
at  age  of  21  years.  In  October,  1893,  he  was  thrown  from  a wagon  and 
struck  on  the  back  of  his  head.  Two  years  later  he  was  trephined  and 
following  the  operation  he  remained  free  from  seizures  for  four 
months.  In  February,  1901,  he  was  trephined  again  and  more  bone 
removed.  Has  had  severe  pains  in  head  since  the  last  operation  and 
the  epilepsy  is  unimproved. 


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BRAIN  SURGERY. 


Result:  No  improvement. 

Case  18. — N.  W.,  female,  aged  20  years.  Family  history  negative. 
Epilepsy  began  at  age  of  13  years.  Fifteen  months  prior  to  the  first 
seizure  she  fell  on  the  ice  and  struck  on  the  right  side  of  the  skull.  In 
November,  1894,  she  was  trephined  over  the  left  parietal  bone.  During 
the  five  months  following  the  operation  she  had  no  seizures.  Attacks 
at  present  4 or  5 per  month. 

Result:  No  permanent  improvement;  some  temporary. 

Case  19. — C.  M.  S.,  female,  aged  27  years.  Family  history:  paternal 
great-grandfather  and  grandfather  insane.  Two  maternal  aunts  epi- 
leptic. Father  inebriate.  Maternal  uncle  died  insane.  Mother  has 
been  epileptic  since  16  years  of  age.  Patient’s  epilepsy  began  at  the 
age  of  11  years.  Assigned  cause,  heredity.  At  the  age  of  20  years  she 
was  trephined  over  the  motor  region  of  the  left  side.  Operation  9 
years  after  the  onset  of  the  disease.  Had  no  attacks  for  one  year 
following  the  operation.  Since  that  time  the  attacks  have  returned. 

Result:  No  permanent  improvement. 

Case  20. — J.  D.  R.,  male,  aged  38  years.  Family  history  negative. 
Epilepsy  began  at  27  years.  Assigned  cause,  injury  to  the  head  by 
being  caught  between  two  ice  wagons.  Eight  years  after  the  onset  of 
the  epilepsy  he  was  trephined  over  the  right  Rolandic  region. 

Result:  No  improvement. 

Case  21. — S.  S.  M.,  male,  aged  22  years.  Family  history  unknown, 
except  that  all  (?)  paternal  relatives  were  intemperate.  Epilepsy 
began  at  11  years.  Supposed  to  be  due  to  injury  to  the  head  by  a kick 
from  a horse.  He  was  trephined  over  the  seat  of  the  injury  and  the 
dura  found  thickened. 

Result:  No  improvement. 

Case  22. — Female,  aged  8 years.  Father  intemperate.  Epilepsy  began 
at  age  of  2 years,  following  an  infantile  cerebral  palsy  which  was  the 
cause  of  her  epilepsy.  At  the  age  of  4 years  she  was  trephined.  Skull 
very  thick.  Operation  2 years  after  the  onset  of  the  epilepsy. 

Result:  No  improvement. 

Case  23. — Female,  aged  38  years.  Family  history  unknown.  Epilepsy 
began  at  the  age  of  8 years.  At  the  age  of  8 years  she  fell  down  stairs 
and  was  also  injured  by  a runaway  horse.  She  had  spasms  imme- 
diately following  the  latter  accident  and  remained  in  an  unconscious 
condition  for  3 days.  She  was  trephined  over  the  left  parietal  bone  3 
days  after  the  injury.  The  convulsions  continued  with  varying  fre- 
quency until  she  was  13  years  old,  when  she  had  immunity  from  them 
until  30  years  of  age.  At  the  age  of  30  years  the  spasms  appeared 
again  and  she  has  had  them  at  various  times  until  April,  1900.  During 
April,  1900,  she  was  operated  upon  for  a cystic  uterus.  The  uterus 
was  removed  with  the  appendages.  There  was  an  imperforate  cervix 
and  the  uterus  had  become  a retention  cyst.  She  made  an  uninter- 


W.  P.  SPRATLING. 


7 


rupted  recovery  from  the  operation  and  since  that  time  she  has  had 
no  return  of  the  convulsions. 

Result:  No  attacks  for  5 years;  cure  probable. 

Case  24. — F.  F.,  female,  aged  9 years.  Family  history  unknown. 
Epilepsy  began  at  the  age  of  3 years.  No  assigned  cause.  At  the  age 
of  6 years  she  was  trephined  over  the  left  parietal  bone. 

Result:  No  improvement. 

Case  25. — A.  S.,  letter  carrier.  G.  M.  Onset  at  32.  Multiple  sclerosis. 
Trephined  June,  1901;  left  parietal  region  (in  Syracuse). 

Result:  No  improvement. 

Case  26. — S.  V.,  aged  20.  No  occupation.  Epilepsy  of  6 years’  dura- 
tion. Has  right  hemiplegia.  Jacksonian  type.  Trephined  by  Dr.  Ger- 
ster  at  Mt.  Sinai  Hospital,  Nov.  18,  1901;  2V^x2^  inches  of  bone 
removed. 

Result:  No  improvement. 

Case  27. — G.  D.  B.,  40.  Laborer,  married.  Onset  at  39.  Family  his- 
tory negative.  Cause  (?)  G.  and  P.  M.  attacks  frequently.  Right  arm 
and  leg  most  frequently  affected.  Trephined  in  Syracuse.  Attacks 
occurred  again  12  days  after  operation.  Operation  six  months  after 
injury  to  head  caused  by  a falling  stove  pipe. 

Result:  No  improvement. 

Case  28. — W.  B.,  10.  Family  history  negative.  Epilepsy  for  9 years. 
Right  hemiplegia.  G.  M.  attacks  beginning  in  right  face,  right  arm 
and  leg.  May  7,  1902,  operated  upon  at  Colony. 

Result:  No  improvement  in  epilepsy. 

Case  29. — J.  A.  S.,  29.  G.  M.  for  25  years,  following  typhoia. 
Paralysis  of  left  arm.  Trephined  at  Massachusetts  General  Hospital  7 
years  before  admission. 

Result:  No  improvement 

Case  30. — W.  B.,  16.  Onset  at  2 years.  Cause  unknown.  P.  and  G. 
M.  Attacks  began  in  left  hand,  extending  to  left  arm,  face  and  head, 
then  to  left  leg.  Trephined  June  7,  1902,  at  Colony.  No  marked  path- 
ological condition  found  at  operation. 

Result:  No  improvement. 

Case  31. — J.  O.  P.,  admitted  Sept.  12,  1902;  aged  16.  At  age  of  7 
received  a fracture  of  skull,  and  was  afterwards  trephined.  Epilepsy 
developed  2 years  after  injury.  G.  M.  No  heredity;  no  paralysis;  two 
or  three  attacks  per  month. 

Result:  No  ipiprovement. 

Case  32. — C.  E.  E.,  aged  26.  Admitted  Feb.  24,  1903.  Epilepsy  for 
14  years,  following  traumatism  to  head.  G.  M.  Paralysis  of  right  arm 
and  leg  and  left  side  of  face.  Trephined  in  Syracuse  in  1899.  Seizures 
more  frequent  after  operation. 

Result:  No  improvement. 


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BRAIN  SURGERY. 


Case  33. — I.  G.,  aged  21.  Admitted  April  29,  1903.  Epilepsy  of  five 
years’  duration.  Cause,  blow  on  head  by  pitchfork.  G.  M.  No  paralysis. 
Trephined  over  right  motor  area  previous  to  admission.  No  definite 
history  of  the  operation. 

Result:  No  improvement;  patient  an  imbecile. 

Twenty  out  of  the  33  cases  cited  above  were  due  to  trauma  of 
the  head.  The  average  duration  of  the  epilepsy  before  the  oper- 
ation was  approximately  5^  years,  being  16  years  in  one  case 
and  3 days  in  another. 

The  results,  noted  in  no  case  less  than  eleven  months  after 
the  operation  and  in  most  of  them  several  years  after,  were  as 
follows: 

In  21,  no  improvement  in  the  disease,  either  temporary  or 
permanent. 

In  8,  the  attacks  were  lessened  in  frequency  and  severity,  the 
operation  being  a part  of  the  treatment  only. 

In  3,  the  disease  was  much  worse  after  the  operation. 

In  1,  apparent  recovery;  the  patient  in  this  case  being  a 
woman,  whose  first  convulsion  had  appeared  after  a severe  head 
injury  in  her  eighth  year,  caused  by  falling  down  stairs.  She 
was  trephined  three  days  after  the  injury,  while  the  convulsions 
continued  five  years  longer,  disappearing  when  she  was  13  to 
recur  at  30.  Some  years  later  when  she  was  admitted  to  the 
Craig  Colony,  her  uterus,  being  a retention  cyst,  was  removed 
with  all  appendages,  the  result  now  being  no  attacks  since  the 
operation,  a period  of  five  years.  In  this  case,  the  operation  on 
the  brain  did  not  relieve  the  convulsions,  the  relief  being  due  to 
the  removal  of  a cause  that  periodically  produced  a form  of 
auto-intoxication.  The  retained  menstrual  discharge  was  a sys- 
temic poison. 

Twenty-eight  of  the  33  cases  were  males;  12  of  these  had  good 
family  histories,  10  had  not,  while  in  6 the  family  history  could 
not  be  ascertained. 

Of  the  5 women,  2 had  good  family  histories,  2 had  not,  while 
1 was  unknown. 

It  is  worthy  of  note  that  none  died  as  the  result  of  the  opera- 
tion. Similar  treatment  of  idiocy  is  attended  with  a compara- 
tively high  rate  of  mortality — fully  20  per  cent,  as  we  shall  see 
later. 


W.  P.  SPRATLING. 


9 


CASES  OPERATED  ON  AT  THE  CRAIG  COLONY. 
Seizure  Records. 


Case  1. — Operation,  April,  1900. 

1900 

January  559 

February  136 

March  131 

April  205 

May  14 

June  0 

July  3 

August  0 

September  0 

October  0 

November  0 

December  3 

Total  1051 

Case  2. — Operation,  April,  1900. 

1900 

January  3 

February  1 

March  7 

April  13 

May  1 

June  11 

July  1 

August  1 

September  6 

October  1 

November  5 

December  4 

Total  54 

Case  3.* — Operation,  November  25,  1900. 

1900 

January  12 

February  14 

March  31 

April  13 

May  19 

June  16 

July  0 

August  0 

September  5 

October  13 

November  2 

December  0 

Total  125 


1901 

1 

3 

3 
1 
2 
0 
2 

4 
7 
7 
1 
0 

31 


1901 

4 

2 

1 

3 

3 

2 

3 

1 

6 

8 

3 

4 

40 


1901 

4 

5 

6 
2 

3 
6 

4 

11 

14 

10 

12 

9 

86 


‘Cases  1,  2,  3 reprinted  from  “Operative  Interference  in  Epilepsy,’ 
by  R.  E.  Doran,  Albany  Medical  Annals,  December,  1902. 


10 


BRAIN  SURGERY. 


Case  4. — Operation,  May  7,  1902 

1902 


January  

February  

March  

April  2 

May  4 

June  2 

July  5 

August  1 

September  2 

October  2 

November  4 

December  0 


1903 

5 

11 

3 

3 


We  have  no  accurate  information  regarding  the  seizures  in 
Case  4 before  admission,  and  are  unable  to  compare  the  number 
of  attacks  before  operation  with  those  occurring  afterward. 

Case  5. — Operation,  June  7,  1902. 


1902 


January  10 

February  13 

March  208 

April  5 

May  6 

June  5 

July  13 

August  7 

September  2 

October  7 

November  10 

December  18 


1903 

25 

13 

75 

2 


(The  large  number  of  seizures  in  the  last  case  in  March,  1902,  was 
due  to  status  epilepticus.) 

Concisely  summed  up,  the  results  in  the  five  cases  operated 
on  at  the  Colony  were  as  follows: 


Case  1. — During  the  4 months  preceding  the  operation  there 
were  1031  attacks.  During  the  4 months  following  there  were 
17  only,  while  during  the  20  months  following  the  operation 
there  were  51  attacks. 


Case  2. — During  the  4 months  preceding  the  operation  there 
were  24  attacks.  During  the  4 months  following,  14;  this  ratio 
of  disease  keeping  about  the  same  thereafter. 

Case  3. — During  11  months  preceding  operation  there  were 
125  attacks.  During  the  11  months  following,  66. 

Case  4. — Number  of  attacks  before  operation  unknown.  Dur- 
ing the  12  months  following  there  were  45. 


W.  P.  SPEATLING. 


11 


Case  5. — Darlns:  5 months  preceding  the  operation  there  were 
242;  daring  the  5 months  following,  54;  during  the  10  months 
following  there  were  193. 

It  will  thus  be  seen  that  absolute  cure  did  not  result  in  any 
case,  while  improvement  followed  in  one  out  of  four — 25  per 
cent.  It  should  be  stated  that  the  five  cases  detailed  were  all 
reoperations  the  first  operation  having  been  performed  before 
the  patient  entered  the  Colony.  It  should  also  be  stated  that  all 
of  the  apparent  improvements  could  not  be  laid  to  the  results  of 
surgery,  for  all  of  the  cases  were  kept  rigorously  under  a defi- 
nite general  treatment,  especially  under  the  suppressive  effects 
of  the  bromides. 

The  marked  improvement  in  Case  1 was  attributed  as  much  to 
the  after  treatment  as  to  the  operation  itself.  The  importance 
of  doing  this  is  clearly  pointed  out  by  Roswell  Park  in  the  fol- 
lowing statement:^ 

“Operation,  when  indicated  and  undertaken,  should  be  re- 
garded as  a first  measure  to  be  followed,  and  often  preceded,  by 
others  looking  to  a correction  of  all  faults  of  diet,  elimination, 
etc.  Long  continued  attention  to  these  matters  is  the  price  of 
success.” 

This  has  long  been  our  doctrine,  and  how  true  it  is  can  only 
be  appreciated  by  those  who  have  watched  through  many  years 
a large  number  of  cases  subjected  to  the  knife,  the  chisel  and  the 
saw.  Surgeons,  as  well  as  neurologists,  are  apt  to  advise  oper- 
ation in  non-traumatic  cases  presenting  distinct  localizing  phe- 
nomena. In  many  cases  of  this  kind  operation  will  prove  use- 
less from  the  fact  that  while  diffuse  cortical  conditions  (three 
words  I would  like  to  emphasize),  productive  of  epilepsy,  may 
have  a central  point  of  greatest  initial  discharge,  the  area  is  too 
diffuse  by  far  for  the  knife  to  remove. 

Roswell  Park  ^ credits  Matthiolus  with  collecting  258  cases  of 
Jacksonian  epilepsy  subjects  of  craniotomy,  the  results  being, 
“ some  20  per  cent  were  reported  as  cured,  though  only  ten  of 
the  entire  number  had  been  followed  for  over  three  years,  and 
only  eighteen  of  them  for  over  a year.  Of  the  others,  15  per 

®The  Surgical  Treatment  of  Epilepsy,  American  Medicine,  Vol.  IV, 
No.  21,  1902. 

*Op.  Cit. 


12 


BRAIN  SURGERY. 


cent  were  reported  improved,  while  in  65  per  cent  there  was  no 
improvement;  13  per  cent  died. 

Braun  collected  30  cases  due  to  trauma,  in  which  Horsley’s 
plan  of  excision  of  the  affected  cortical  area  was  carried  out,  13 
of  the  patients  bein^  reported  as  recovered,  9 improved,  and  8 
unimproved.  Of  the  13  reported  as  recovered,  only  3 were  fol- 
lowed for  3 years,  a fact  that  must  vitiate  any  claim  so  striking 
as  this  one  appears  to  be. 

Kocher  regards  the  methods  of  electrically  locating  the  area 
to  be  excised,  in  the  manner  advised  by  Horsley,  not  sufficiently 
accurate  to  always  reach  the  seat  of  the  disease. 

Broca  and  Manbrac  credit  Ferrier  with  reporting  a total  of 
21  cases  of  partial  epilepsy  operated  on,  with  12  recoveries,  6 
ameliorations,  and  3 negative  results,  adding:  “It  must  be  re- 
membered that  such  observations  are  often  published  before  6 
months  have  elapsed.”  They  hold  that  recoveries  are  not  rare, 
and  that  the  relief  of  headache  and  attenuation  of  the  severity 
of  the  attack,  which  mean  a great  deal,  are  at  times  attained. 

In  1893  Starr  reported  13  cases  operated  on,  with  3 cures;  but 
three  years  later  admitted  that  the  cases  reported  as  cured  were 
reported  too  early. 

Gowers  believes  that  trephining  in  idiopathic  epilepsy  is  never 
justifiable. 

It  is  unfortunate,  on  the  whole,  that  so  little  help  can  be 
gained  from  statistics;  not  that  they  are  essentially  unreliable, 
but  because  the  view-point  of  those  who  make  them  is  often  so 
widely  different. 

There  is  also  often  failure  to  specify  the  type  of  epilepsy  in 
which  the  operation  is  done,  the  comparison,  of  statistics  being 
consequently  impaired.  Another  thing  that  creates  confusion  is 
the  lack  of  any  rule  or  uniformity  in  the  length  of  time  that 
should  elapse  before  results  are  announced.  Bergmann  rather 
caustically  remarks  that  this  is  sometimes  done  “before  the 
wound  heals.” 

It  is  difficult  to  fix  a time  limit  in  this  respect.  Such  limit,  in 
our  opinion,  should  be  regulated  in  a measure  by  the  type  of 
epilepsy  operated  on — the  cause  likewise  being  considered.  As  a 
general  rule,  it  should  not  be  less  than  two  or  three  years  in  any 
case,  while  in  all  cases  possible  observations  should  be  kept  up 
after  that.  If  we  accept  two  or  even  three,  years  as  the  period 


W.  P.  SPRATLING. 


13 


thfit  should  elapse  after  the  operation  before  results  are  reported 
the  ratio  of  recoveries  from  epilepsy  under  brain  surg^ery  will 
be  disappointingly  small. 

RESULTS  OF  BRAIN  SURGERY  IN  IDIOCY  AND  IMBECILITY. 

The  picture  of  success  following  brain  surgery  in  epilepsy 
just  presented  was  not  bright. 

In  idiocy  and  imbecility,  under  the  light  of  increasing  time, 
its  hue  is  more  sombre  still;  so  disappointing  is  it  in  color,  in 
fact,  that  we  feel  a strong  inclination  to  turn  from  it,  saying, 
“ There  is  nothing  in  it  that  brings  any  gratification;  we  do  not 
want  it,  nor  are  we  disposed  to  help  in  its  creation.” 

Craniotomy,  linear  and  “ a lambeaux,”  was  introduced  by 
Lannelongue,  who  published  25  cases  in  1891  in  which  he  claimed 
results,  not  only  so  far  as  recovery  from  the  operation  was  con- 
cerned, but  also  as  to  mental  improvement  in  a remarkably  short 
time,  so  striking  and  so  novel,  that,  to  use  Jacobi’s  words, 
“Physicians  began  to  hope,  surgeons  to  glory,  and  the  idiotic 
children” — he  significantly  adds— “let  us  see.” 

Nothing  finer  or  more  exhaustive  on  the  subject,  from  the 
standpoint  of  the  incredulous,  if  not  of  the  positive  opponent, 
has  appeared  in  medical  literature  to  our  knowledge  since  Jaco- 
bi’s masterly  address,  “ Non  Nocere,”  delivered  before  the  Elev- 
enth International  Medical  Congress  in  Rome  in  April,  1891. 

The  essence  of  that  address,  so  true  then,  is  none  the  less  true 
now;  the  pathology  of  mental  deficiency  has  not  changed,  nor 
have  we  in  all  these  years  elevated  the  cause  of  craniotomy  in 
the  treatment  of  idiocy  in  any  degree. 

The  “furor  operandi”  so  generally  acclaipied  ten  years  ago 
has  largely  passed  away,  but  it  may  return  at  any  time,  when 
the  great  principles  that  underlie  “Non  Nocere”  in  this  par- 
ticular field  of  medical  work  will  await  a wide  application. 

“What,”,  asks  Jacobi,  “are  the  underlying  conditions  of 
idiocy?  ” In  the  main,  as  shown  by  the  results  of  the  autopsies, 
they  are  as  follows:  “ Chronic  encephalitis,  diffuse  or  circum- 
scribed; diffuse  (syphilitic)  disease  of  the  blood  vessels;  arrest 
of  vascular  development  in  the  cortex;  inequality  in  the  hemi- 
spheres; inequality  in  the  peripheral  cortical  layer  on  the  two 
sides;  defect  of  the  third  frontal  convolution  and  the  island  of 
Reil;  meningo-en cephalitis,  with  thickening  and  adherence  of 


14 


BRAIN  SURGERY. 


the  pia  and  brain,  such  as  may  occur  after  forceps  or  trauma, 
kephalo-hsematoma  internum,  spontaneous  hemorrhages;  embo- 
lism from  heart  disease;  thrombosis  from  cholera  infantum,  fol- 
lowed by  destruction  of  cerebral  cells  and  atrophy  of  the  cor- 
tex.” 

Starr  found  the  last  condition  in  21  cases  out  of  343.  In  the 
same  cases  in  32  instances  he  also  found  maldevelopment  and 
apparent  atrophic  conditions  of  the  brain  structure  of  the  hemi- 
spheres, chiefly  cortical,  the  cells  resembling  those  of  a new- 
born child,  but  with  no  apparent  gross  defects  in  the  brain; 
atrophic  and  hypertrophic  sclerosis,  congenital  or  post-natal,  in 
97 ; atrophy  by  softening  produced  by  embolism  or  thrombosis, 
and  limited  to  certain  arterial  districts,  in  23;  arrest  of  devel- 
opment, such  as  porencephaly,  in  132;  cysts,  which  produced 
atrophy  by  pressure  or  were  associated  with  the  atrophy  due  to 
the  original  lesion,  in  14;  hemorrhages  which  were  discernible 
by  the  remains  of  a clot,  or  by  the  blood-staining  of  a cyst,  of 
the  pia,  or  of  sclerotic  tissue,  in  18. 

In  addition  to  all  these  causes  of  idiocy,  there  remain  to  be 
mentioned  hydrocephalus,  microcephalus  and  premature  ossifi- 
cation of  the  fontanelles  and  sutures. 

These,  in  the  main,  are  the  pathological  conditions  in  the  brain 
that  surgical  intervention  seeks  to  remove  or  modify  for  the  re- 
lief of  idiocy  and  imbecility,  and  while  it  would  be  of  the  great- 
est interest  to  look  deeper  into  the  relative  frequency,  degree 
and  kinds  of  the  different  causes  and  pathological  states,  we 
must,  perforce,  for  lack  of  time  pass  on  to  what  surgery  —never 
more  brilliant  or  wondrous  in  the  world’s  history  than  it  is  to- 
day— has  been  able  or  unable  to  accomplish  in  the  way  of  relief. 

While  the  literature  is  replete  with  histories  of  individual 
cases,  that  teach  valuable  lessons,  I am  able  to  present  194  such 
cases  under  two  heads  in  condensed  form;  the  first  group  in- 
cluding the  more  immediate  results  in  111  cases;  the  second, 
results  somewhat  more  permanent  in  83  cases. 

. TABLE  I,  ONE  HUNDRED  AND  ELEVEN  CASES.  ^ 

Case  1. — Microcephalus,  imbecility  from  early  synostosis  in  a child. 
Left  craniectomy.  Death  24  hours  after  operation.  (Lane;  Journal  of 
Am.  Ass.,  Jan.,  1892.) 

“Both  tables  are  made  up  from  the  results  noted  by  Lowenstein,  in 
references  given. 


W.  P.  SPRATLING. 


15 


Case  2. — Girl,  4 years,  microcephalus,  craniectomy  in  two  sittings. 
Results  excellent.  Marked  improvement  of  general  condition.  (Lan- 
nelongue;  Gaz.  hebdom.,  1890.) 

Cases  3-26. — 24  cases.  13  boys,  11  girls.  Microcephalies  and  idiots, 
young  subjects,  showing  (with  or  without  epileptiform  crises),  motor 
or  psychic  troubles.  Operation  for  the  most  part  “Kraniektomie  A 
lambeaux.”  Dura  opened  in  one  case.  Three  died  after  operation. 
In  a very  large  number  of  cases  mental  improvement;  also  in  regard 
to  the  gait.  (Lannelongue;  Gaz.  des  hop.  1891,  Congres  frang.  de  chir., 
1891.) 

Cases  27-30. — First  case,  craniectomy.  Improvement,  but  a second 
operation  was  without  results.  Second  case,  19-month  girl.  Idiocy. 
Premature  suture  synostosis.  Failure  of  fontanelles.  Craniectomy  on 
both  sides.  After  three  months,  improvement,  distinct,  if  not  satisfac- 
tory. Third  case,  16-month  boy.  Microcephalic  idiot.  Synostoses  of 
suture  and  fontanelles,  convulsions.  Craniectomy.  Death  immediately 
after  operation.  Fourth  case,  4i/^-year  girl.  Microcephalic  idiot. 
Failure  of  fontanelles,  convulsions,  craniectomy.  Death  immediately 
after  operation.  (W.  Keen;  Amer.  Jour.  Med.  Sciences,  1891.) 

Case  31. — ^Girl,  3%  years.  Microcephalic  idiot,  epilepsy.  Premature 
synostosis  of  sutures  and  fontanelles.  Left  parietal  bone  lapped  over 
right.  Left  arm  paralyzed.  Left  craniectomy.  Brilliant  results  3^/^ 
months  after  operation.  Epilepsy  disappeared.  Arm  useful.  (Ran- 
schoff;  Medical  News,  1891.) 

Cases  32-34. — ^^Three  cases.  Only  in  one  exact  history;  6-year  boy. 
Microcephalus.  Idiot.  Synostosis.  Convulsions.  No  trace  of  intelli- 
gence. Craniectomy.  Excellent  results.  In  the  other  two  cases  good 
results.  (Wyeth;  Med.  Record,  1891,  and  Gaz.  hebdom.,  1891.) 

Case  35. — 2i/^-year  boy.  Microcephalic  and  idiotic.  Could  not  walk, 
stand  or  speak.  Epilepsy.  Left  craniectomy.  Eight  weeks  after  opera- 
tion, improvement.  Epilepsy  disappeared.  (Will.  Morrison;  Med.  Rec., 
1891.) 

Cases  36-37. — 3-year  boy.  Microcephalic  and  idiotic.  Craniectomy. 
Improvement  in  ten  days. 

7-year  boy;  microcephalic  and  idiotic.  Craniectomy  with  incision 
over  the  speech  center.  Death  after  operation.  (V.  Horsley;  Brit.  M. 
J.,  1891.) 

Case  38. — 8-month  boy.  Microcephalic;  idiotic;  blind  both  sides. 
Left  craniectomy.  Sight  improved.  Great  improvement.  (Miller  R. 
Shalders;  Ibid.,  1892.) 

Cases  39-45. — (1)  3%-year  boy.  Microcephalic;  idiotic;  epilepsy. 
Right  craniectomy.  Improvement. 

(2)  4-year  boy.  Microcephalic  and  idiotic;  epilepsy.  Left  craniec- 
tomy. Result,  negative. 

(3)  18-year  boy.  Microcephalic;  idiotic;  epilepsy.  Craniectomy. 
Death. 


16 


BRAIN  SURGERY. 


(4)  15-year  boy.  Same  symptoms  as  above.  Craniectomy.  Death  In 
26  hours. 

(5)  9-year  boy.  Microcephalic;  idiotic;  epilepsy.  Craniectomy. 
Improvement 

(6)  Symptoms  in  12-year  girl  as  in  5.  Right  craniectomy.  Result, 
negative. 

(7)  14-month  child.  Microcephalic;  idiotic.  Left  craniectom>. 
Death,  soon. 

Case  46. — 3-year  child.  Did  not  walk,  sit  or  speak.  Salivation. 
Right  craniectomy.  Improvement.  (M.  Gould;  Med.  News,  1891.) 

Case  47. — 4i/^-year  boy.  Microcephalic  and  idiotic.  Epilepsy.  Crani- 
ectomy on  right  side.  Improvement.  The  author  is  not  absolutely 
satisfied  with  this  improvement.  (Clayton  Parkhill;  Ibid.,  1892.) 

Case  48. — 9 years;  microcephalic  and  idiotic.  Like  3-year  child. 
Right  craniectomy.  Improvement.  After  two  years  grew  much  worse 
Died  in  1893.  (Preugrueber;  Gaz.  hebdom.,  1892.) 

Cases  49-50. — 4-year  girl.  Microcephalic;  idiotic;  craniectomy  both 
sides.  Improvement. 

lli/^-year  boy.  Microcephalic  and  idiotic.  Left  craniectomy.  Im- 
provement. (Chenieux;  Ibid.) 

Case  51. — 3-year  boy.  Microcephalic.  Slight  improvement  in  seven 
months.  (Largeau;  Ibid,  und  Congres.  frang.  de  Chirurg.,  1892.) 

Case  52. — Eight  months;  microcephalic;  craniectomy.  After  opera- 
tion, deterioration,  then  slight  improvement.  (Gersuny;  Gaz.  hebdom., 
1893.) 

Case  53. — Microcephalic  and  idiotic.  Temporary  craniectomy.  Im- 
provement. (Jonnesco;  Ibid.,  1898.) 

Case  54. — 16  months;  microcephalic  and  idiotic.  Craniectomy  both 
sides.  Improvement,  but  death  after  five  days.  (Griffiths;  Ibid.) 

Case  55. — 19  months;  microcephalic  and  idiotic.  Craniectomy.  Re- 
sult, negative.  (Boyd;  Ibid.) 

Case  56. — 8 years;  microcephalic;  epilepsy.  Left  craniectomy,  im- 
provement. (Auger;  Congres  franc,  de  Chirurg.,  1891.) 

Cases  57-58. — 4 years;  microcephalic  and  idiotic.  Craniectomy.  Re- 
sult, negative. 

2-year  boy;  microcephalic  and  idiotic;  epilepsy.  Craniectomy.  Death 
21  hours  after  operation.  (Mannoury;  Ibid.) 

Case  59. — 8-month  girl.  Microcephalic  and  idiotic.  Craniectomy. 
Improvement  at  first.  Five  weeks  after  operation  again  the  old  condi- 
tion. Death  shortly  after.  (Heurteaux;  Ibid.) 

Case  60. — 3%-year  girl.  Microcephalic  and  idiotic.  Craniectomy  on 
both  sides.  More  intelligent  expression.  (MacClintock;  Centralbl  f. 
Chir.,  1892.) 

Case  61. — 11-month  boy.  Microcephalic.  Craniectomy,  left.  Improve- 
ment. Operation  should  be  repeated.  (E.  Kurz;  Ibid.,  1893.) 


W.  P.  SPRATLING. 


17 


Case  62. — Microcephalic  child.  Craniectomy.  No  result  reported. 
(Postempsky;  Ibid.) 

Cases  63-64. — 1%-year;  microcephalic  boy.  Craniectomy,  both  sides. 
No  result  after  one  year. 

21/^-year;  microcephalic  girl.  Craniectomy,  both  sides.  Death  8^ 
weeks  after  operation,  unimproved.  (Tillmanns;  Ibid.,  1894.) 

Case  65. — 14-year  boy;  idiot.  Right  craniectomy.  Seven  trephine 
buttons  removed.  Improvement,  (A.  Szpanbock;  Ibid.,  1895.) 

Cases  66-77, — 12  cases;  microcephalic  and  idiotic.  Ages  2i/^  to  8% 
years.  Linear  craniectomy.  3 improvements;  5 negative  results;  1 
doubtful;  3 deaths.  (C.  L.  Dana;  Ibid.,  1897.) 

Case  78. — 31^-year  boy;  microcephalic  and  congenital  occipital  men- 
ingoceles. Idiocy.  Craniectomy  left  and  right,  and  extirpation  of  the 
meningoceles.  21^  years  after  operation  physical  and  mental  improve- 
ment. (Parona;  Jahresbericht  f.  Chir.,  1895;  and  Contributo  alia 
Chirur.  Cerebrale  e spinale.) 

Cases  79-90. — 9 operated  cases.  The  majority  craniectomies;  Two 
improvements.  (Oed  & Cotterall;  Ibid.) 

Cases  91-92. — 1,  after  a year,  no  improvement;  1 died.  (Isuardi; 
Ibid.) 

Case  93. — 9-month  child;  microcephalic  and  idiot.  Craniectomy  both 
sides.  Result,  negative.  Death  after  2 years.  (Bourneville;  Lombard 
& Pillier;  Ibid.,  1896.) 

Case  94. — 8-year  girl.  Idiot.  Craniectomy.  Improvement.  (Reca- 
sens;  Ibid.) 

Case  95. — 5-year  idiot.  Craniectomy.  Result,  doubtful.  (Lilanus; 
Ibid.) 

Cases  96-102. — 7 cases  of  microcephalus  and  idiocy.  Craniectomy. 
In  all  seven  cases,  result  negative.  (Blank;  Ibid.,  1895.) 

Case  103. — 3%-year  boy.  Microcephalus  and  idiocy.  Craniectomy 
both  sides.  Improvement.  (Joos;  Corresp.-bl.  f.  Schweizer  Aerzte. 

1893. ) 

Case  104. — 14-month  girl.  Microcephalus.  Craniectomy,  circular. 
Improvement.  (Dumont;  Ibid.) 

Case  105. — 12-year  child.  Microcephalus.  Craniectomy,  both  sides. 
A little  improvement.  (Schede;  Deutsche  Med.  Wchnschr.,  1895.) 

Cases  106-107. — 15-year  girl.  Idiocy.  Microcephalus.  Left  crani- 
ectomy. First  improvement,  then  old  condition.  Result,  negative. 

2-year  boy.  Microcephalus  and  idiocy.  Craniectomy,  left  and  right. 
Death  seven  days  after  operation.  (Beck;  Prager  Med.  Wchnschr., 

1894. ) 

Case  108. — 2-year  boy.  Microcephalus  and  idiocy.  Craniectomy,  both 
sides  in  two  sittings.  Improvement.  Half  a year  after  operation  no 
progress.  No  improvement  after  second  operation.  After  eight  weeks 
a slow  improvement  noted  by  the  mother.  (Akermann;  Volkmann’s 
Sammlung  Klin.  Vortrage,  1890-94,  Nr.  90.) 


18 


BRAIN  SURGERY. 


Cases  109-110. — (1)  6-year  boy.  Microcepbalic  and  idiotic.  (2) 
microcephalic  and  idiotic.  Left  craniectomy.  Both  children  neater. 
(Rabow  & Ronx;  Therap.  Monatshefte,  1891.) 

Case  111. — Girl.  Microcephalic  and  idiotic.  Epilepsy.  Craniectomy 
both  sides.  Result,  negative.  (Starr;  1894.) 

SUMMARY  OF  RESULTS  IN  ONE  HUNDRED  AND  ELEVEN  CHILDREN 

OPERATED  ON. 

19,  or  17^,  died  in  consequence  of  operation  or  soon  after. 
25,  or  22.5^,  were  operated  upon  with  no  result. 

10,  or  9^,  were  operated  upon  with  slight  result,  but  not  satis- 
factory. 

24,  or  21.5^,  were  improved  in  stated  ways. 

30,  or  27^,  improvement  without  reports  as  to  its  character. 

3,  or  3^,  with  no  reports  as  to  the  results  given  in  general. 

TABLE  II,  EIGHTY- THREE  CASES. 

Cases  1-4. — 3 boys;  1 girl.  Ages  3,  5,  7,  9 years.  All  were  micro- 
cephalic and  idiots.  2 were  epileptics.  Linear  craniectomy.  2 died 
after  operation.  Old  hemorrhage  of  brain.  One  disappeared  after  the 
first  improvement.  One  was  improved.  (Parkhill;  Denver,  June  19, 
1899.) 

Cases  5-26. — 22  cases,  in  age  from  14  months  to  8 years.  All  were 
idiots  and  microcephalic.  Linear  craniectomy.  The  results  were  such 
that  Lamphear  since  1896  has  not  done  the  operation  in  general.  Some 
died  within  a few  years  after  the  operation.  (Manoury;  Chartres,  Juin 
10,  1899.) 

Cases  27-41. — 15  cases  of  craniectomy.  5 died  immediately  after  the 
operation.  1 died  after  having  become  maniacal  a short  time  after  the 
operation.  6 showed  absolutely  no  result.  3 were  only  quieter  after 
the  operation.  (Roswell  Park;  Buffalo,  June  22,  1899.) 

Cases  42-45. — See  other  table  (27-30).  2 died  immediately  after  the 
operation.  2 showed  practically  negative  results.  Keen  from  his  re- 
sults became  opposed  to  the  operation.  (W.  Keen;  Z.  Lt.  Hamburg, 
June  30,  1899. 

Case  46. — ^See  38  in  last  table.  Died  four  years  after  operation.  At 
first  improvement;  then  2 years  after  operation  return  to  old  condi- 
tion. (Miller  R.  Shalders;  London,  June  15,  1899.) 

Case  47. — See  case  81  in  last  letter.  The  writer  says:  “The  operation 
of  Lannelongue  has  given  no  result;  no  one  of  my  acquaintance  prac- 
tises it  in  France.”  Hemicraniectomy.  Result  nil.  (Doyen;  Rheims, 
Juin  19,  1899.) 

Cases  48-49. — 4-year  girl.  2-year  boy.  Microcephalic  and  idiotic. 
Craniectomy.  1 died  immediately  after  operation.  1 showed  improve- 


W.  P.  SPKATLING. 


19 


ment  in  the  first  2 or  3 months  after  operation.  5 months  later  the  old 
condition  returned  permanently.  (Mannoury;  Chartres,  Juin  10,  1899.) 

Cases  50-52. — 11-year  child.  Microcephalic.  13-year  boy«  Microceph- 
alic,  idiot  and  epileptic.  4i/^-year  boy.  Microcephalic;  idiot;  spasms. 
Craniectomy,  both  sides.  At  first,  results  . Then  “The  patients  remain 
idiotic  and  epileptic  and  have  only  temporary  ameliorations  for  1 or 
iy2  months.  (Jaboulay;  Lyon,  Juin  14,  1899.) 

Case  53. — Case  61  of  first  table.  At  first  improvement.  Then  patient 
grew  worse  and  died  in  1897.  (E.  Kurz;  Florenz,  Juni  16,  1899.) 

Cases  54-75. — 22  cases  of  microcephalus,  idiocy  and  epilepsy  in 
children  not  over  5 years.  (66-77  in  first  table.)  Craniectomy  of 
various  kinds.  5 died.  14  were  operated  upon  without  results.  3 were 
improved.  (C.  L.  Dana;  N.  Y.,  Sept.  18,  1899.) 

Case  76. — Result,  nil.  Child  died  IV2  years  after  operation.  The 
whole  left  hemisphere  showed  cystic  degeneration.  (Gersuny;  Wien; 
Juni  25,  1899.) 

Cases  77-78. — 1 (Dumont,  104,  Table  1).  Epilepsy  remained  till 
death,  1896.  (Operation,  1893.)  2 (Joos  & Walder,  103,  Table  1). 

After  2 years  the  results  disappeared  and  the  patient  was  in  a sad 
state.  (Dosseker;  Corresp.-bl.  f.  Schweizer  Aerzte,  1899.) 

Case  79. — Idiocy.  Craniectomy,  both  sides.  No  change  after  opera- 
tion. After  five  years  the  old  animal  condition.  (Czerny.) 

Cases  80-82.— 3 cases.  2 girls;  1 boy.  Ages  6,  7,  11  years.  Idiocy;  1 
with  microcephalus.  Circular  craniectomy.  2,  much  quieter,  one  died 
after  some  years  an  idiot.  (Dumont;  Bern.,  Oct.  21,  1899.) 

Case  83. — 3i/^-year  girl.  Microcephalic  and  idiot.  Epilepsy.  Craniec- 
tomy. At  first  improvement,  then  deterioration.  The  child  became 
insane  and  died  in  this  condition  in  1900.  (Perry;  Kolombo,  Sept.  20, 
1899,  together  with  letter  of  Jonathan  Bird  Kandy,  July  10,  1899.) 

SUMMARY  OF  RESULTS  IN  EIGHTY-THREE  MORE  PERMA- 
NENT CASES. 

20,  or  24^,  died. 

54,  or  75^,  unimproved. 

9,  or  lOi^,  improved. 

Seventy-five  out  of  83  received  no  benefit.  The  9 who  were 
improved  showed  it  mostly  in  being  quieter.  This  was  the 
result  in  a case  of  restless  imbecility  and  epilepsy  operated  on 
at  the  Colony;  mental  deterioration  after  the  operation  being 
rapid.  The  sudden  lull  in  purposeless  activity  that  follows  the 
operation  in  some  cases  must  not  be  mistaken  for  gain  in 
mental  powers.  The  opposite  is  generally  the  rule. 

Note  the  results  in  Roswell  Park’s  15  cases.  Five  died  imme- 
diately after  the  operation;  one  died  after  having  become 


20 


BRAIN  SURGERY. 


maniacal  a short  time  after  it;  6 showed  absolutely  no  improve- 
ment; while  3 only  were  quieter.  Also  the  results  obtained  by 
Lamphear  in  22  cases,  ranging  in  age  from  14  months  to  8 years, 
all  microcephalic  idiots,  the  results  being  such  that  since  1896 
Lamphear  has  not  performed  the  operation.  Doyen  says,  ‘‘The 
operation  of  Lannelongue  has  given  no  results;  no  one  of  my 
acquaintance  practices  it  in  France.” 

Dana’s  22  cases  turned  out  as  follows:  5 died;  in  14  there 
were  no  results;  while  3 were  improved;  none  being  over  five 
years  of  age,  all  having  idiocy  and  epilepsy. 

Wilson  states  that  since  Fuller,  of  Montreal,  trephined  an 
idiot’s  skull,  in  1878,  to  improve  the  mental  condition,  and 
Lannelongue.  of  Paris,  did  linear  craniectomy  on  microcephalic 
idiots  with  the  same  object,  craniectomy  has  been  done  a num- 
ber of  times  with  varying  success.  Some  think  with  Lanne- 
longue that  the  premature  ossification  of  the  skull  is  the  cause 
of  the  microcephalus  and  deficient  brain  development,  and  jus- 
tify the  operation  on  the  theory  that  after  it  the  imperfectly 
formed  brain  improves  its  function  and  takes  a greater  amount 
of  nourishment. 

“With  the  hypothesis,”  says  Lowenstein,\  “ of  the  primary 
synostosis  of  the  sutures  and  fontanelles  and  the  secondary 
hindrance  of  brain  development,  stands  or  falls  the  right  of 
Lannelongue’s  operation.  The  hypothesis  is  false  and  therefore 
the  operation  is  not  a suitable  one.  Death  or  no  result  fol- 
lows. ” 

Keen  says  that  no  good  can  possibly  come  from  operation  on 
an  idiot  with  a skull  of  average  size,  in  extreme  microcephalus, 
or  in  a patient  over  seven  years  of  age,  and  concludes  that  in 
some  few  cases  of  moderate  microcephalus,  craniectomy  is  justi- 
fiable; that  slight  improvement  will  follow  in  a small  number  of 
cases,  but  in  the  majority  there  will  be  no  change.  He  places 
the  mortality  at  from  15  to  20  per  cent. 

Dana  holds  that  craniectomy  is  justifiable  in  a selected  class 
of  cases.  He  believes  that  the  clinical  reports  show  improve- 
ment too  often  for  the  facts  to  be  ignored.  He  thinks  the  oper- 
ation is  indicated  in  simple  lack  of  development  rather  than 
where  extensive  lesions  exist. 


W.  P.  SPRATLING. 


21 


Jacobi  gives  41  operations  on  33  cases  with  14  deaths,  and  of 
the  19  recoveries  from  the  operation  there  was  slight  improve- 
ment in  8 and  considerable  improvement  in  2,  and  says: 

“ It  appears  that  in  the  face  of  so  many  deaths  and  so  few 
results,  the  operation  is  not  promising  to  mankind. 

The  operations  thus  far  performed  do  not  effect  what  they 

were  intended  for;  they  do  not  even  enlarge >the  cavity 

If  any  cases  be  at  all  amenable  to  treatment  by  such  operations, 
they  must  be  those  of  incomplete  premature  ossification  of  the 
sutures  and  fontanel  les.” 

Goethe  once  said  that  ‘‘The  most  interesting  book  that  could 
be  written  would  be  a treatise  on  the  errors  of  miankind,”  and 
Jacobi  adds,  “Let  us  see  to  it  that  our  mistakes  do  not  swell 
that  book.” 

Carl  Beck  concludes  that  craniectomy  is  justifiable  and  apt  to 
be  successful  in  microcephalus  with  idiocy.  Acquired  and  late 
forms  give  a better  prognosis  than  the  congenital  forms,  while 
the  dangers  of  the  operation,  he  says,  are  not  very  great. 

Norbury  is  of  the  opinion  that  the  basis  of  much  cerebral  sur- 
gery in  mentally  defective  states  has  been  grossly  theoretical. 
“ Especially,”  he  goes  on  to  say,  “ does  this  apply  to  operations 
for  the  relief  of  microcephalus.” 

Operation  from  a pathological  standpoint  is  utterly  hopeless. 
Synostosis  is  not  necessarily  indicative  of  arrested  mental  devel- 
opment, and  it  is  not  a factor  in  producing  microcephalus. 

Broca  has  modified  Virchow’s  views  by  saying  it  is  a result 
and  not  a cause  of  microcephalus.  Lannelongue  now  accepts 
the  same  view,  but  believes  that  as  the  brain  is  capable  of  de- 
velopment until  past  the  8th  year,  the  operation  is  justifiable  as 
a stimulant  to  brain  growth. 

Idiocy  is  a “vice  of  the  entire  organism,”  and  the  improve- 
ment of  the  mental  condition  depends  upon  the  improvement  of 
the  entire  physical  system.  This  cannot  be  done  by  the  assist- 
ance of  surgical  means,  for  brain  growth  is  not  dependent  upon 
stimulus  from  such  a source,  but  from  true  physiological  educa- 
tion—the  training  of  the  bodily  powers — without  which  no 
mental  improvement  can  be  expected. 

The  marked  improvement  noted  in  the  few  cases  which  have 
survived  the  operation  of  linear  craniectomy  is  not  to  be  won- 
dered at,  as  all . interested  in  the  case  have  sought  by  every 


22 


BRAIN  SURGERY. 


means  to  improve  the  child,  and  it  must  respond  to  a certain  ex- 
tent. 

On  the  whole,  Norbury  is  vastly  in  favor  of  educational  in 
contradistinction  to  surgical  measures  for  the  improvement  of 
the  mental  conditions  of  the  feeble-minded. 

Bourneville,  in  reviewing  in  detail  the  histories  of  13  original 
cases,  concludes:  “It  is,  then,  the  medico-pedagogical  treat- 
ment to  which  we  must  turn  and  upon  which  we  must  depend. 
This  is  for  the  amelioration,*  and  even  the  cure,  of  a notable 
portion  of  children  afflicted  with  the  divers  forms  of  idiocy. 

Pelliet  states  that  the  pathological  anatomy  of  the  brains  of 
idiots  confirms  the  opinion  expressed  by  Bourneville.  It  is  not 
difficult  to  formulate  conclusions  on  the  results  to  be  expected 
from  surgery  of  the  brain  done  for  the  possible  relief  of  epi- 
lepsy and  congenital  mental  defect. 

If  the  epilepsy  is  general  and  of  some  years  duration,  we  need 
scarcely  expect  a cure,  though  in  selected  cases  operations  may 
ameliorate  the  symptoms  to  a marked  extent — temporary  ameli- 
oration being  oftener  obtained  than  that  which  is  permanent. 

If  the  epilepsy  is  unessential,  reflex,  rudimentary  in  type,  or 
of  short  duration,  and  the  operation  removes  the  cause  early 
enough,  we  may  expect  the  convulsions  to  cease  in  many  cases, 
provided  the  patient  is  free  from  the  vices  of  heredity  that  are 
always  beyond  the  reach  of  the  knife. 

We  fail  to  find  a single  case  of  congenital  mental  defect  in 
which  a normal  mental  status  was  established  through  surgical 
intervention.  We  find  many  reports  of  cases  benefited — the 
degree  not  being  given — so  that  it  is  extremely  difficult  to  judge 
of  specific  results  in  any  case. 

The  fact  that  such  operations  are  so  few,  as  compared  to  what 
they  were  ten  years  ago,  is  the  strongest  argument  against  their 
utility  in  the  great  majority  of  cases.  Surgical  interference 
may  still  be  used  in  isolated  cases  of  idiocy,  but  it  seems  clear 
that  it  is  slowly  finding  its  position  in  rational  treatment  along 
a plane  far  lower  than  seemed  possible  at  the  time  of  its  inaug- 
uration. 

REFERENCES. 

Broca  & Manbrac:  Traite  de  Chirurgie  Cerebrale,  1896. 

Binne,  (J.  P.) : The  Operative  Treatment  of  Non-microcephalic 
Idiocy.  Ann.  Surg.,  Phil.,  1894,  XIX,  453. 


W.  P.  SPRATLING. 


23 


Norbury,  (P,  P.):  Surgical  versus  Educational  Methods  for  Im- 
provement, &c.,  of  Feeble-minded.  Am.  J.  Insan.,  Utica,  1892,  XLIX, 
391. 

Jones,  (B):  Limitations  in  the  Treatment  of  the  Idiot.  Am.  J. 
Surg.  & Gynaec.,  Kansas  City,  1893-4,  240.  (Not  in  library.) 

Bourneville:  Cranes  et  Cerveaux  dTdiotie.  Craniectomie.  Bull. 
Soc.  Anat.  de  Paris,  1896,  LXXI,  49. 

Lamphear,  (F.) : The  Operative  Treatment  of  Idiocy.  Internat. 
Clin.,  Phil.,  1893,  Ser.  3,  II,  227. 

Lowenstein,  (S.):  Ueber  die  Mikroc.  Idiot,  u.  ihre  chirur.  &c.  nach 
Lannelongue;  Beitz,  (Z.):  Klin.  Chir.,  Tubingen,  1900,  XXVI,  133. 

Wilson,  (W.  J.):  Craniectomy,  &c.  Canada  J.  M.  & S.,  Toronto, 
1899,  VI,  425. 

Park,  (Roswell) : The  Surgical  Treatment  of  Epilepsy.  American 
Medicine,  Nov.  13,  1902. 


